Medical home study finds limited quality improvement and no significant savings

The patient-centered medical home model emphasizes physician and hospital coordination, with the goal of improving the quality and efficiency of health care, as well as improving the patient’s experience of receiving care. This model has received endorsements from professional associations and policymakers, and the Affordable Care Act directs additional resources toward these programs as a way to enhance and train primary care providers.

A recent study published in JAMA evaluated one of the largest multipayer medical home pilots in the country, the Southeastern Pennsylvania Chronic Care Initiative, which was implemented from 2008 to 2011. Researchers used surveys and claims data to assess the quality, utilization, and cost of care at the 32 participating primary care clinics – which earned sizable bonuses for achieving NCQA recognition as patient-centered medical homes – and compared findings to a control group of 29 comparable clinics.

Previous studies of patient-centered medical home pilots have revealed modest quality improvements and no discernible effects on utilization and costs. Even so, the researchers in this study hypothesized that the Pennsylvania initiative’s size, bonus structure, and involvement of multiple payers (including commercial insurers and Medicaid) would have better equipped the pilot program to achieve quality improvements. However, the study found that although the pilot clinics successfully adopted structural changes and received NCQA recognition, the clinics saw limited quality improvement and no significant savings.

“Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.”

Mark Friedberg and colleagues, JAMA

The researchers point to several possible reasons behind the minimal improvements. Participating clinics did so on a voluntary basis and may have been higher performing before joining the pilot program. Also, the pilot “was focused on quality improvement for chronic conditions and featured early financial rewards for NCQA recognition, possibly distracting from other activities intended to improve the quality and efficiency of care.” The pilot also did not have any “direct incentives to contain costs.”